Reanimating the Dead

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It’s trauma season once again. As room 9 after room 9 roll in the door the rising 2nd and 3rd years will soon be dealing with traumatic arrest patients (if they haven’t already). While the ED resident works to control the airway, the trauma team is placing bilateral chest tubes and a cordis. All of this while the nurses and techs continuously perform compressions and give 1mg of epi every 3-5 minutes, while inadvertently interrupting everything else going on. At the end of the day are all those compressions and all the epi going to change outcomes? We know in medical cardiac arrest it will but is traumatic cardiac arrest different?

Reanimating Patients After Traumatic Cardiac Arrest A Practical Approach Informed by Best Evidence discusses 5 key principles to guide management. The emphasize this is only for isolated traumatic cardiac arrests and that if there is any indication that a medical cardiac arrest occurred prior to a trauma following guidelines such as ACLS should be given priority.

 

The 5 Key Principles:

  1. Start or Stop
  2. Deprioritrize Chest Compressions
  3. Fix Ventilation
  4. Stop the Bleeding
  5. Fix the Physiology

 

 

Start or Stop:

When do you start or stop a traumatic resuscitation? What Factors do you consider? Well there is some food for thought:

Favorable Prognostics Factors:

  1. Penetrating injury, particularly to the Thorax
  2. Vitals Signs at any time
  3. Signs of Life at any time
  4. Short Duration (<10min)
  5. Cardiac Contractility on POC USN

Without 1 of these signs, survival is <1%. Important to keep in mind when EMS is giving a report and you are try to determine how long to attempt a resuscitation.

Spectrum of Output States:

They note for their practice the category of “dead” does NOT receive any further resuscitation. The note this is in part to save the vital limited resource of blood prodcuts. I also found it interesting that they separate PEA from pseudo-PEA from severe hypovolemia. Thats why having the cardiac probe in hand on arrival can save be useful in determining how far you are going to push the resuscitation.

 

 

Deprioritize Chest Compressions

Chest compressions may work for medical arrest but the pathology behind traumatic arrest is so vastly different all they do is get in the way of more vital procedures: intubation, chest tubes, central access, cardiac USN. Until all this has been established it would probably be better just to hold compression. Be warned however this will likely be an uncomfortable experience for the nurses/techs.

 

Fix Ventilation:

Referring back to Table 3 we can clearly see that establishing an airway and decompressing both sides of the chest should be top priority in a traumatic arrest.

Remember that traumatic arrests are a low flow state and while most patients while not require a induction agent or paralytic if you do use a paralytic use TWICE the dose.

 

Stop the Bleeding:

Simple and straight forward if it’s bleeding make it stop. Direct Pressure, tourniquets, topical hemostatic agents (which as far as I’m aware we don’t have) and pelvic binders are all easily performed in room 9. Thoracotomy is also something to consider discussing with Trauma early on in these resuscitations. Both the Eastern Association for  the Surgery of Trauma and the Western Trauma Association recommend thoracotomy and though their conditions vary penetrating trauma to the torso and arrest for less than 15 minutes seems to be a good rule of thumb.

 

Fix the Physiology: 

Pretty straightforward recommendations that we do everyday:

  1. Keep the Patient warm to prevent exacerbating coagulopathies
  2. Establish AccessL Large bore (14-18 gauge) IV access above the diaphragm, IO access of the proximal humerus, 8 or 9-Fr CVC preferably subclavian while avoiding multiple lumen CVCs
  3. Minimize fluids and transfuse blood products 1:1:1 and allow for permissive hypotension

They go into some post-resuscitation recommendations as well when it comes to “fix the physiology” but those are less important to use.  I would recommend that everyone should briefly review this article as it has a lot more information and reasoning behind their recommendations.

 

 

Coagulopathy & Synthetic Cannabis

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As you may have heard recently, an outbreak of coagulopathy cases has occurred in the U.S., primarily in Illinois but also in other states (Indiana, Maryland, Missouri and Wisconsin), associated with synthetic cannabinoid (marijuana) use.  So far, there have been 94 cases nationally, with 2 deaths.

We have identified the first Kentucky case that appears to be linked to this outbreak. As per CDC, clinical signs of coagulopathy include “bruising, nosebleeds, bleeding gums, bleeding disproportionate to injury, vomiting blood, coughing up blood, blood in urine or stool, excessively heavy menstrual bleeding, back or flank pain, altered mental status, feeling faint or fainting, loss of consciousness, and collapse.”

Providers in Kentucky should maintain a high index of suspicion for vitamin K-dependent antagonist coagulopathy in patients presenting with clinical signs of coagulopathy, bleeding unrelated to an injury, or bleeding without another explanation and with a possible history of synthetic cannabinoids (e.g., K2, Spice, and AK47) use. These patients can be screened for coagulopathy by checking their coagulation profile (e.g., international normalized ratio (INR) and prothrombin time (PT)).

Should you see a patient exhibiting signs indicative of coagulopathy, call Poison Control at 1-800-222-1222 for diagnostic and clinical consultation and report the case to your local health department immediately.  For night and weekend public health case reporting, please call 1-888-9-REPORT(1-888-973-7678) for the Kentucky Department for Public Health’s Epidemiology On-Call Service.

These cases often require therapy with fresh frozen plasma and high doses of Vitamin K for extended periods (up to months) due to the long-acting nature of the poison.

Please see the CDC Health Alert at https://content.govdelivery.com/accounts/USCDC/bulletins/1e6dac3 for more information on the current outbreak.

Thank you for your attention to this emergent public health issue and for the hard work and diligence you exhibit every day in your clinical practice.

For additional information specific to this message, contact Doug Thoroughman, PhD, MS, CAPT, US Public Health Service, CDC Career Epidemiology Field Officer, Kentucky Department for Public Health at telephone: 502-564-3418 x4315 or email at douglas.thoroughman@ky.gov

Paraspinous blocks for migraines

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Many of you have probably heard me discuss my love of paraspinous blocks for migraine headaches, and I know several of you have learned how to do them on me when I have a migraine. This seems to be one of those slightly voodoo things that I would have sworn could never work, until I tried it and had almost immediate relief when several traditional abortive therapies failed.

For those who haven’t, this is an incredibly easy procedure that takes a minimal amount of time and can give real relief in migraine patients. There is no complicated anatomy involved, no significant technique or skill level required, and is safe enough that I have talked many novices through the procedure on a patient with supervision.

To do the block, the most important part is selecting the correct patient to increase your chances of success. Technically it won’t hurt anyone to do a block on them, but I’ve quickly learned this has a near zero chance of working in patients who state only an IV cocktail of dilaudid and phenergan works for their migraines. I’ve also found minimal effects on those who are texting while under bright lights and listening to music. I have had the most success on patients that look absolutely miserable: the ones curled up into a fetal position, actively vomiting, crying, with all the lights out and begging you to do ANYTHING to make their headaches go away. These people also tend to be quite enthusiastic about a treatment that you can administer on the spot and will work within 5-10 minutes typically. For all the things we do that sometimes have fairly minimal objective evidence of relief, it makes me very happy to walk back into a room in 20 minutes and see this previously miserable patient looking completely normal, stating their headache has resolved, and being ready to discharge… all without medications from pharmacy or an IV.

I typically use bupivicaine and do not use any subcutaneous lidocaine as the youtube video attached at the end of this post shows. I draw up 3cc, planning to use 1.5cc on each side. Your landmarks will be your C6 or C7 spinous process. I typically go C7 because it is easy to find by asking patients to flex their chin to their chest, and I like to keep things easy. C7 is the most prominent spinous process at the base of the neck. Not sure if you’re at C6, C7, or T1? Even better, for this block it doesn’t really seem to matter because it still works! You’ll be injecting approximately 2cm laterally to the edge of the spinous process, give or take half a centimeter based on body size. Again, don’t get too caught up in the details- it seems to work at 1.5cm to 3cm laterally to the process. After a swipe with an alcohol prep (bonus points- you can hand the patient another alcohol prep pad to inhale for relief of their nausea and vomiting! See last week’s journal club article for more details), you’ll insert the needle (any size, but a 25g hurts less) parallel to the ground in a straight anterior tract. I insert the needle 1.5-2cm. Aspirate to make sure you aren’t in a vessel, then inject 1cc of bupivicaine deep, and the remaining .0.5cc while withdrawing your needle. Repeat on the opposite side, stick a bandaid on, and reasses in about 20 mins. If it’s going to work, most seem to start to get significant relief in about 10 mins. If unchanged in 20ish minutes, I proceed to other therapies.

When I’m in first care, I typically will take a bottle of bupivicaine and a needle/syringe into the room when I walk in for an initial evaluation. If the patient seems to be a good candidate and is agreeable, I go ahead and do the block at that time. By the time I do my charting or see the next patient, I typically have a good idea of if the patient has improved, or rather if I need to start ordering other therapies.

Quick and easy, and I have about a 60-75% success rate on patients. Pretty good considering a standard migraine patient will likely take a couple of hours to receive IVFs, meds and reassess. You can sometimes get these people dispo’d in less than 30 minutes!

I’ve attached a quick video for you visual learners

ED Antibiotics & Shortages

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Couple things:
Cefazolin and Ceftriaxone will now (temporarily) only be in 2g Syringes in the ED Accudose machines due to fluid shortages.
Option 1: Just order 2g (while this may be more than necessary for some patients, there’s really no harm–renal patients if admitted would just have an interval adjustment).
Option 2: Order 1g, and wait for Pharmacy to tube up the 1g dose.

Unasyn is being pulled from the ED Accudose: you can still order, may just take a bit more time for pt to get as it will come from pharmacy.

IV fluids, Fentanyl, Morphine, Dilaudid are all on shortage. We have them, use them when appropriate, but consider oral fluids/pain meds if appropriate.

Let me know if you have questions/concerns. Thanks for reviewing. I’ll update you as things change/develop.

Ross

Lung Masses

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All,

Just a heads up, spoke with Hala Karnib, one of the Pulmonary Fellows and she requested if we have any lung masses (not just your basic pulmonary nodule repeat CT 3-6 months), that they be called and notified.
If these patients don’t require admission, they are able to and prefer to set them up for close follow up with Bronchoscopy, even within a couple days.
We had a patient yesterday who had been seen last summer in our ED for an unrelated complaint but ended up having a Lung Mass diagnosed; she was notified of this but didn’t really have follow up set up (though she had a PCP). This isn’t necessarily our fault, but had she been plugged into the Pulm system they would have contacted her to ensure she wasn’t lost to follow up (which she was and now presents with worsened metastatic cancer).
At least per her, they’d like to be called about these patients anytime. Thanks,

Ross

Wound prophylaxis – Should lip lacs get antibiotics (and few others)?

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During my review for 72 hour returns we had a through and through lip laceration come in that returned with a wound infection a few days later.  This prompted me to look up current recommendations as I’m pretty sure that I haven’t been giving antibiotic prophylaxis for this.

Searching literature, Tintinalli and UpToDate…… Most superficial wounds do not require prophylaxis, however, through and through lip lacerations were an area of uncertainty and debate….

Tintinalli  – “matter of provider preference.”

UptoDate – no clear clinical evidence to say that these wounds should receive antibiotic prophylaxis , however, due to the pathogens of the oral cavity, they recommend prophylaxis.

Current literature – Review article in 2008, Annals of Emergency Medicine, Mark DG et al – review of studies do not show a statistically significant benefit; however, the only double-blinded randomized control trial showed a trend toward benefit in patient’s that were compliant with therapy.

Some other stats – Rate of infection in wound treated in the ED (Tintinalli)

Head and neck 1-2%

Upper extremity 4%

Lower extremity 7%

Oral wounds – 9-27%

If giving prophylaxis then Pen VK or Clindamycin is recommended for 3-5 days.

For other oral wounds, <1cm, no need to close. Close if large gap susceptible to food getting trapped, and counsel on good oral hygiene.  Dental and OMFS usually recommend d/c with chlorhexidine gluconate oral rinse (0.12%) (Peridex) and will have patients swish and spit after meals to keep the wound from contamination with food particles.

My take away from this is strongly consider antibiotic prophylaxis with through and through oral wounds as they are higher risk for infection with oral flora; however, not an absolute must based on the current evidence.  Be sure to emphasize good oral hygiene, and as always, close follow up with good return precautions.

Other wounds to strongly consider prophylaxis due to increased risk for infection are mammalian and human bite wounds, crush injury, puncture wounds, and wounds with either fresh or salt water contamination, or patients who are immunocompromised, asplenic, advanced liver disease, associated edema (according to the IDSA).

Open fractures and wounds with joint capsule violation should receive antibiotic prophylaxis.

Reminder: Update Tetanus and simple lacerations do not need antibiotic prophylaxis.

Hepatitis A Outbreak

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All,
In case you haven’t heard, we’re in the midst of a Hepatitis A outbreak in Louisville (there’s been much larger ones elsewhere, including San Diego). I apologize if this is a long post and will try to keep organized but want to get this out sooner rather than later. Some things I think you should know:

  • It’s transmitted via the fecal-oral route (hence why food handlers with HepA should not be working)
  • High risk patients include Homeless patients, IV drug users, and Men who have sex with men (so a big portion of our patients)
  • Consider Hepatitis in patients with: Fever, malaise, N/V/D, abdominal pain + either jaundice or elevated AST or ALT.
  • It requires reporting to the Health Dept
  • Patients should be placed in contact/enteric isolation (similar to C. Diff).
  • Hands must be washed with soap and water (hand sanitizer isn’t good enough)!
  • Rooms must be cleaned by EVS with Bleach. Please clean your stethoscopes as well.
  • The incidence of fulminant hepatic failure is <1% (it’s higher in those with liver disease and with concomitant Hep B or C)
  • Treatment is generally supportive, with hydration and electrolyte replacement as needed. Infection with Hepatitis A generally leads to immunity, thus do not need to vaccinate those with a diagnosis of Acute Hepatitis A.
  • Patients are contagious until ~1 week after appearance of jaundice
  • Patients and family members should be counseled on the route of transmission and should receive a dose of the Hepatitis A Vaccine (they can be directed to the Louisville Metro Dept of Public Health and Wellness at 400 E. Gray St.)
  • There is no chronic Hep A State.
  • The Acute Hepatitis Panel checks for HAV IgM, HepB Core Antibody, IgM, HepB Surface Antigen, and Hepatitis C antibody (thus can tell you if Acute A, and maybe B, but not whether Hep C is acute or chronic). You can order the specific Hep A IgM in Cerner, though it’s probably good to know whether B or C is present also.
  • Those with Altered sensorium, INR > 1.5, a PT > 5 seconds above normal or with concomitant illnesses may require admission.
  •  One of the recommendations is to administer the vaccine to our at risk populations, but PLEASE wait on this until I have further info on our stock/supply of the vaccine.
  • The attached PDF has a questionnaire that the health dept is requesting be filled out and sent to them in order to reduce the spread of HAV, so please be aware of it and remind the nursing staff to try to get it filled out. If they’re unsure about it discuss with charge nurse to get the form.

Sorry this is so long but hope this helps. For any issues just email me and I’ll try to sort it out.

*See the attached PDF for information from the Health Dept/ULH. as well as the CDC link on Hepatitis A

Hep A Provider Recommendations 12.2017

https://www.cdc.gov/hepatitis/hav/havfaq.htm

 

Primum Non Nocere

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First, do no harm.  Sounds easy enough, but have you ever ordered a “screening CT?”  Have you ever been “better safe than sorry?”  We’re all aware of the nebulous risk of radiation from the imaging we order, we know that getting stuck for blood hurts, and sometimes medications have side effects, but what happens when the results of tests themselves are the things harming patients?

This article does a great job exploring this question.  I’ve also found patients much more receptive to my explanations as to why I’m not ordering the thing they think they need since reading this and spending some time thinking about it.  There are definitely times when my honest indication for ordering that Head CT is “patient wants it…” but in general this article has pushed me a little closer to the minimalists’ corner.

Overkill – Atul Gawande

Just the Nuggets

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Hey Everybody,
Not sure if you’ve heard of the Emergency Medicine Cases blog (it’s good), but they have a “Just the Nuggets” segment that they will email you and covers a wide range of topics but summarizes them down to the most important aspects of different illnesses (current segment is on GI Bleeds). Just thought I’d share the link for you to check out and decide if you’d want to subscribe to it (I have no ties to the blog).

New EM Cases Feature: Just The Nuggets

Life and Death: An Ethical Dilemma

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I had just arrived for my night shift when my colleagues notified me that a level one trauma was coming in in about 10 minutes. EMS had called over the radio, “61-year-old female with self-inflicted GSW to the left chest. Tachycardic, 94% on room NRB. Vitals otherwise stable. ETA 10 minutes.” A level one trauma was paged out, and I headed to the trauma room to prepare. A chronically ill-appearing female rolled in, in no distress at all, sitting mostly upright on the EMS stretcher. The tension lessened somewhat due to her stable appearance.

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“I don’t want anything done for me. I have a living will. I don’t want any help. I just want to die.” These were the first words she spoke as she arrived.

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I had not encountered this before. I hesitated for a second before telling Carol (her name has been changed to protect her identity) that since this was a suicide attempt we were obligated to help her. I turned to my attending, questioning what I had just said and asked what I actually should do.  My attending said that the assumption was that she was not of sound mind (did not have capacity) and therefore required assistance. In addition, to her dismay, EMS had not brought her living will to the ED.

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Carol’s work-up in the trauma room showed a GSW to the left chest just lateral and above the left nipple, and an exit wound to the left upper back. Shockingly, she had no pneumothorax on the chest x-ray or ultrasound, and no cardiac injury. The bullet had struck her breast implant and traversed around her ribs, fracturing one, and exited out her back without causing any major injury.

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“Let me die. I don’t want to live.” Carol made sure we understood her wishes, but we ignored them for the time being. She was taken to the CT scanner and was stable, and eventually was admitted to the trauma service.

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Carol had a nurse assigned to her as a one-on-one sitter in the ED, who, over the span of the next two hours, learned a lot about her. Carol was a very sick individual. She had had uterine cancer, a cystectomy and subsequent urostomy, transverse myelitis resulting in paralysis of both legs, many abdominal surgeries, and multiple other comorbid medical conditions. She had been in the hospital numerous times already this year, and had actually been seen by palliative care as an inpatient two months prior. In the nurse’s perspective (and mine, after hearing about their conversations), she was of sound mind. She had capacity, and she understood her current situation very well. She was depressed, but had more than enough reason to be. She knew she was chronically ill, and was apparently told by her doctors that nothing else could be done for her situation, and that she would end up dying from one of her many chronic illnesses. On her last visit to the ED (the day prior, diagnosed with a UTI), her code status was clearly a DNR in our system. Upon arrival to the ED the following day, this was reversed, and she was made a full code.

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It is rather well known that most individuals who live after a failed suicide attempt end up regretting it. However, Carol didn’t – not one bit. “I’ve lived a long, good life. I know what’s coming for me, and I don’t want to experience it. I don’t want to suffer. I’m ready to die.”

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Since my encounter with Carol, I set out to research what I should do in this situation, and most of my research led me to advice from the legal world. If a physician knowingly treats somebody who has a signed DNR order, the consequences can be dire, including suspension, revocation of license, and a fine of up to $10,000(1). However, there seems to be no real consensus as to what the right answer is in the case of attempted suicide. There are many case reports detailing this situation, and in the majority of cases, care is ultimately withdrawn and the DNR is respected. Sometimes, it depends on the state in which the Advance Directive was created, as there may be a clause in which a suicide attempt voids the AD. One article even stated that time should be dedicated to decide if the “suicide attempt was reasonable, given the patient’s terminal condition”(2).

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As much as we would like medicine to be black and white, it isn’t, and this case only reinforces that fact. So, in the chance you are involved in a situation like this, what is the right thing to do? From what I have read, the right answer for us as emergency physicians is probably to treat the patient like you would any other that comes to your door. Oftentimes, these situations require lengthy psychiatry consults and an ethics consult, and extensive discussions with family and the patient (if possible). Most people who attempt suicide and survive end up regretting their decision, and you should treat your patient as though they will, too.

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(1) http://www.caseyfrank.com/articles/how-to-reconcile-directives-with-suicide.pdf

(2) https://www.chausa.org/docs/default-source/general-files/case-study—a-terminally-ill-suicide-attempt-patient-in-the-ed-pdf.pdf?sfvrsn=0

Push Dose Pressors

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Are you all tired of hearing about sepsis yet?  How about the fact that we apparently suck at sepsis?  However, I think we can all recognize when someone comes in with severe septic shock.  You know, the sick, hypotensive, altered patient with a source of infection.  With a low blood pressure, we just need to keep pushing more fluids right?  Just keep pushing them until they are in pulmonary edema.

Well, what could we possibly do to improve outcomes?  The longer they are hypotensive, the more end organ damage they are going to sustain, and the worse the outcomes.  I know that most of you all listen to EMCrit.  If you don’t, you should.  So while waiting for that central line to be placed by our intern (and we know that can take a while, j/k interns, I love you) and waiting for the levophed gtt to be started, we can be like Weingart and give some push dose pressors.  Not only could they be used for that septic patient needing a boost in BP, but can also be used for the peri- or post-intubation or sedation patient that becomes hypotensive.

Epi-It’s not ideal to give code dose epi to someone with a pulse.  Instead take a 10 mL syringe and fill it with 9 mL of NS.  Then draw up 1 mL of epi from the cardiac amp.  This gives you 10 mcg/mL of epi.  Now, give 0.5-2mL (5-20mcg) q1-5 min until improved BP.

Phenylephrine- Draw up 1 mL of phenyl from a vial that is 10 mg/mL and put in a 100 mL bag of NS.  This gives you 100mL of phenylephrine at the concentration of 100mcg/mL   Now you draw up 10mL into a syringe at push 0.5-2 mL (50-200mcg) q1-5 min.

And for your convenience, here is a link to a PDF from EmCrit with the instructions on how to mix these.  Take a pic, keep it on your phone.  While doing this, don’t forget patient safety.  Make sure you’re labeling your syringes when you mix up push dose pressors.  Avoiding medication errors is always plus.

Also, until you are comfortable doing this, make sure you are collaborating with your attending and the pharmacist if they are there at the time.

Finally, read this article on safety considerations in push dose pressors.

And for added fun, read all room9ER posts in Danny DeVito’s voice.  It makes everything better.